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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200804
Report Date: 02/21/2024
Date Signed: 02/21/2024 06:35:33 PM


Document Has Been Signed on 02/21/2024 06:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:SERENE CARE WINCHESTERFACILITY NUMBER:
079200804
ADMINISTRATOR:RANCES, RONANFACILITY TYPE:
740
ADDRESS:4984 WINCHESTER DRTELEPHONE:
(925) 625-0543
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:6CENSUS: 5DATE:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Thelma Hababag CaregiverTIME COMPLETED:
07:00 PM
NARRATIVE
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At approximately 4:15PM, Licensing Program Analysts (LPAs) Carol Fowler and Tonica Syess-Gibson arrived unannounced to conduct a Required 1 Year annual inspection and met with Caregivers, Thelma Hababag and Renato Hababag. Ronan Rances, Administrator arrived at 4:59PM. Facility has an approved fire clearance for 2 ambulatory and 4 non-ambulatory residents for a total capacity of 6 residents.

LPAs conducted a tour of the facility and observed the following: the facility was clean and at a comfortable temperature 73 degrees with all exits free from obstruction. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Toxins were secure and not accessible to residents. There is a sufficient supply of hygiene products, paper products, and linens available for resident use.
LPAs reviewed 5 resident records which were incomplete. LPAs reviewed three (3) staff records which S2 and S3 were incomplete . LPAs reviewed three staff files. Administrator's Certificate #6025731740 was current with an expiration date of 03/06/2024.

The facility last fire and evacuation drill was conducted on 01/05/2024. Facility's fire extinguishers were last inspected 01/09/2024. Emergency Disaster Plan updated on 01/08/2024 Smoke detectors and carbon monoxide detectors were tested and operational. The amount of fresh and non-perishable foods are within regulation. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Continued on LIC809C.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: SERENE CARE WINCHESTER
FACILITY NUMBER: 079200804
VISIT DATE: 02/21/2024
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Continued from LIC809.

LPA requested the following documents to be submitted to CCLD by 2/28/2024.
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan (last page)
  • Liability Insurance

LPAs interviewed one (1) resident.

LPAs observed the following deficiencies:
  • At 4:47pm, LPAs observed screen in shared bathroom was ripped.
  • At 4:59pm, LPAs observed unlocked medication in kitchen cabinet.
  • 5:24pm, LPAs observed record review two (2) out of three (3) files reviewed were incomplete.


Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.


Exit interview conducted and a copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/21/2024 06:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SERENE CARE WINCHESTER
FACILITY NUMBER: 079200804

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not having medication locked which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/22/2024
Plan of Correction
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2
3
4
Administrator agreed to locked centrally stored medication and conduct in service with staff about pre pouring and having medication locked. DEFICIENCY CLEARED DURING VISIT
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 02/21/2024 06:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: SERENE CARE WINCHESTER
FACILITY NUMBER: 079200804

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
87412 Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having staff personnel records complete with health screening, personnel record (LIC501) which poses a potential health and safety risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator agreed to complete staff personnel files and submit an sample and check list to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4